Musculoskeletal Flashcards
What is the majority of disease risk determined by in Ankylosing spondylitis
90% have HLA-B27
Male predominated
Describe the typical disease course for Ankylosing spondylitis
Before 30 years old
Insidious onset of lower back pain with spinal morning stiffness relieved by exercise
What are the 3 articular features of Ankylosing spondylitis
Inflammatory back pain:
Patients usually have morning stiffness and pain that starts in the sacroiliac joints and radiates to the buttocks. There is often tenderness of the sacroiliac joints. Advanced diseases sees the loss of lumbar lordosis and exaggeration of thoracic kyphosis with the neck stooped forward (Question mark posture).
Peripheral enthesitis:
Achilles tendonitis, Plantar fasciitis and tibial tuberosity. Painful in the morning - potential swelling
Peripheral arthritis:
Asymmetric joint involvement including - Hips, Shoulder, Chest wall, Pubic symphysis
What are the extra-articular features of Ankylosing spondylitis
Eyes - Acute anterior uveitis
CV - Aortitis to AR, Fibrosis to AV Block
Resp - Limited chest expansion to Restrictive, Fibrosis of upper lobes
Renal - IgA nephropathy
Neuro - 2o to fractures of fused spine - Cauda equina
Met - Osteopenia/Osteoporosis
What are the investigative results in Ankylosing spondylitis
Potential normocytic anaemia - FBC
Inflammatory markers may be elevated - ESR, CRP
Sacroiliitis or enthesitis/Spinal Osteopenia - XR
MRI - More sensitive
DEXA - Osteoporosis
Seronegative - -ve Rheuamtoid factor and ANA
What is Gout
Gout is a crystal arthropathy.
This is arthritis due to monosodium urate (MSU) crystal deposition within joints causing acute inflammation and tissue damage. These deposits are called Tophi
What joints are usually affected in Gout
Most of the time it is the MTP joint of the big toe (podagra)
Other joints: Ankle, Foot, Small joints in hands, Wrist, Elbow, Knee
Potential to be polyarticular but is usually mono
What is the primary cause of Gout and what are the precipitating factors to this
The primary cause if hyperuricaemia usually due to inadequate excretion of uric acid from purine nucleotides
RFs: MALE
Dietary: Meat, Seafood, Alcohol, High triglycerides
Drug: Diuretics, Chemotherapy
Medical: Obesity, CHD, CKD, DM, HF, HTNm Psoriasis
What are long term complications of Gout
Urate deposits - Tophi
Renal disease - Stones, interstitial nephritis
What are the signs and symptoms of Gout
Swollen, tender, red joints - Peaks within 24hrs. Attack resolves in 5-15 days untreated.
Potential - Tenosynovitis, bursitis and cellulitis
Chronic tophaceous gout - Large deposits around extensors and ears
Crepitus and deformity
What are the investigative findings in gout
Negatively birefringent urate needle-shaped crystals and increased WCC - Polarised light microscopy of synovial fluid
High serum urate
Junta-Articular erosions - XR
What is Pseudo-gout
This calcium pyrophosphate deposition rather than monosodium urate and usually affecting larger joints
What is the presentation of Pseudo-gout
Acute monoarticular or oligoarticular arthritis.
Usually affects the knees
Often also wrists, shoulders, ankles, hands and feet. Almost any joint may be affected.
Presentation is similar (but usually milder) to acute gout, with acute joint pain and swelling.
Affected joints are acutely inflamed with swelling, effusion, warmth, tenderness and pain on movement.
Attacks may be associated with fever and raised white cell count.
What are the investigative findings in Pseudo-gout
Positive intracellular or extracellular birefringent rhomboid-shaped crystals - Polarised light microscopy of synovial fluid
Soft tissue calcium deposition - XR
What are the risk factors and associations of Fibromyalgia
RFs Female Middle age Low household income Divorced Low educational status
Chronic fatigue syndrome
IBS
Chronic headache syndrome
What are the main signs and symptoms of Fibromyalgia
Pain - Chronic (>3months) and widespread (Left and right, above and below diaphragm)
Fatigue - Profound with unrefreshing sleep and significant fatigue and pain with small increases in exertion.
Widespread and severe tender points
Other features: Morning stiffness Paraesthesiae Headaches Low mood
What are investigations in Fibromyalgia geared towards
Exclusion of Rheumatoid arthritis Polymyalgia rheumatica Vasculitis Hyothyroidism Myeloma
Who usually gets Giant cell arteritis
Temporal arteritis:
Woman older than 50
If they are younger then consider Takayasu’s.
It is associated with Polymyalgia rheumatica
What are the signs and symptoms of Giant cell arteritis
Headache
Temporal artery and scalp tenderness
Loss of vision
Malaise
Dyspnoea
Weight loss
Morning stiffness
Risk of irreversible bilateral vision loss
What are the normal investigative results in Giant cell arteritis
Increased ESR and CRP Thrombophilia Increased ALP Anaemia Biopsy within 14 days of starting steroids - Beware of skip lesions
How is Giant cell arteritis treated
No visual symptoms - Oral Prednisolone
Visual symptoms - IV MethylPrednisolone
What are the symptoms of localised and generalised Osteoarthritis
Localised disease:
Hx Physically active
Pain and crepitus on movement
Pain is worse with prolonged activity.
Morning stiffness lasting under 30 minutes. (Longer than this may be suggestive of RA)
Joint instability can lead to perceived lack of power
Generalised disease:
Joint tenderness
Derangement and bony swelling (Heberden’s at DIP, Bouchard’s at PIP)
Reduced range of movement
Which joints are usually affected in localised and generalised Osteoarthritis
Localised:
Knee or Hip
Generalised:
DIP, PIP, CMC joints
What are the investigative findings in Osteoarthritis
Plain XR Loss of joint space Osteophytes Subarticular sclerosis Subchondral cysts
Potentially elevated CRP
What are the risk factors for Carpal tunnel syndrome
Women
Genetic:
Short stature
Fix
Hereditary neuropathy
2o: Obesity Colles fracture Trauma to wrist SOL in wrist DM Hyperthyroidism Menopause Inflammatory arthritides Acromegaly Renal dialysis Amyloidosis
Pregnancy
What are the characteristic features of Carpal tunnel syndrome
Aching pain in the hand and arms (especially at night), and paraesthesiae in thumb, index, and middle fingers: relieved by dangling the hand over
the edge of the bed and shaking it (remember ‘wake and shake’).
There may be sensory loss and weakness of abductor pollicis brevis ± wasting of the thenar eminence. Light touch, 2-point discrimination, and sweating may be impaired.
What are the investigative findings in Carpal tunnel syndrome
Tinnel’s - Tapping lightly over the median nerve at the wrist causes a distal paraesthesia in the median nerve distribution.
Phalens - Flexing the wrist for 60 seconds causes pain or paraesthesia in the median nerve distribution.
ENG - The median nerve is stimulated proximal to the carpal ligament and compound muscle action potential is picked up over the thenar eminence.
EMG - Useful but ENG better
US - Confirming
What is Systemic sclerosis
A multisystem autoimmune disease characterised by functional and structural abnormalities of small blood vessel, fibrosis of skin and internal organs, and production of auto-antibodies
What are the antibodies involved in Systemic sclerosis
90% of cases are ANA positive
30-40% have anticentromere antibodies
Limited: 70-80% Anticentromere antibodies
Diffuse: 40% Antitopoisomerase-1
20% anti-RNA polymerase
What are the 2 main types of Systemic sclerosis and the main features of both
Diffuse Cutaneous Systemic Sclerosis (40%) Raynaud's phenomenon Followed by skin changes with truncal involvement Tendon friction Joint contracture Early lung disease Heart, GI and renal disease Nail-‐fold capillary dilatation
Limited Cutaneous Systemic Sclerosis (60%) CREST Syndrome Calcinosis Raynaud's phenomenon (O)esophageal dysmotility Sclerodactyly Telangiectasia
What are the signs and symptoms of Systemic sclerosis separated by system
Skin - Raynaud’s disease
Hands - Initially swollen and painful then later they thicken and tighten and become shiny. Changes in pigmentation and Finger ulcers
Face - Microstomia - Puckering of skin around mouth. Telangiectasia
Lungs - Fibrosis to hypertension
Heart - Pericarditis or effusion, fibrosis, HF
GI - Dry mouth, oesophageal dysmotility, GORD, Gastric paresis
Kidneys - Hypertensive renal crisis, Chronic renal failure
Neuromuscular - Trigeminal neuralgia, wasting and weakness
Others - Hypothyroidism, impotence
Aside from the 1st line investigation of Systemic Sclerosis what other investigations can supplement the finding of ANA antibodies
Lungs - CXR, PFTs, CT Heart - ECG, Echo GI - Endoscopy, Barium studies Kidneys - U&Es, creatinine clearance Neuromuscular - EMG, biopsy Joints - Radiography
What is Systemic lupus erythematosus (SLE)
This is a multi-system inflammatory autoimmune disorder associated with tissue damage caused by vascular immune complex deposition
What are the presentations of SLE
General: Fever Fatigue Weight loss Lymphadenopathy Splenomegaly
Raynaud’s
Oral ulcers
Skin rash - Malar/Discoid + Photosensitivity
Systemic:
MSK - Arthritis, tendonitis, myopathy
Heart - Pericarditis, arrhythmias, Libman-Sacks endocarditis
Lung - Pleurisy, effusion, atelectasis
Neurological - Headache, stroke, cranial nerve palsies
Psychiatric - Depression, psychosis
Renal - Glomerulonephritis
What are the diagnostic criteria for SLE
SLE is an appropriate diagnosis when 4 or more criteria (at least 1 clinical and 1 lab) are met or biopsy-proven lupus nephritis with positive AN and anti-DNA
Clinical: Acute cutaneous lupus Chronic cutaneous lupus Non scarring alopecia Oral/nasal ulcers Synovitis Serositis - Lung or Pericardial Urinanalysis - Proteinuria or red cell casts Neurological features Haemolytic anaemia Leucopenia Thrombocytopenia
Lab criteria ANA +ve 95% Anti-dsDNA Anti-Smith Abs Antiphospholipid Abs Low complement \+ve Direct Coombs test
What is Cervical spondylosis
Progressive degenerative process affecting the cervical vertebral bodies and intervertebral discs, and causing compression of the spinal cord and/or nerve roots
What are the common presentations of Cervical spondylosis
Neck:
Neck stiffness
Pain: Arm (Stabbing or dull) Face Breast Chest
Legs:
Weak and stiff legs
Gait disturbances
General:
Paraesthesia
Weakness
Clumsiness
What are the signs of Cervical spondylosis
Arms: Atrophy of the forearm and hand muscles Segmental muscle weakness in a nerve root distribution Hyporeflexia Sensory loss Pseudoathetosis
Legs - In cord compression Increased tone Weakness Hyper-reflexia Babinski +ve Reduced vibration and proprioception
What are the main investigations used in Cervical spondylosis
Cervical MRI - Bone destruction, Cord/ Nerve compression
Cervical XR - Degenerative joint, degenerative disc, fracture
What is Sjögren’s syndrome
A chronic systemic inflammatory autoimmune disorder characterised by lymphatic infiltration into exocrine glands especially the lacrimal gland and salivary glands
What are the classifications for Sjögren’s syndrome
It can be primary occurring alone or secondary occurring with another autoimmune inflammatory disease such as Rheumatoid arthritis, SLE or Systemic sclerosis (Scleroderma)
What are the main features of Sjögren’s syndrome
Dry eyes
Dry mouth
Parotid swelling
Dry URT - Dry cough
Dry skin on hair
Dry vagina
Reduced GI mucus secretions - Reflux oesophagitis, gastritis, constipation
General: Depression, weight loss, fever, fatigue
What are the main investigations for Sjögren’s syndrome
Schrimer’s test - A filter paper is placed in the lower conjunctival sac. The test is positive if less than 5 mm of paper is wetted after 5 minutes.
Antibodies - Antibodies to the ribonucleoproteins 60 kD Ro and La are found in up to 90% of patients with Sjogren syndrome.
Fluorescein/Rose Bengal Stains
May show punctate or filamentary keratitis
Other Investigations
Reduced parotid salivary flow rate
Reduced uptake or clearance on isotope scan
Biopsy of salivary or labial glands
What is Septic arthritis
This is defined as infection of 1 or more joints caused by pathogenic inoculation of microbes.
What are risk factors for Septic arthritis
Increased age >80 DM Prior joint damage Joint surgery Prosthetic joints Skin infection in combination with joint prosthesis Immunodeficiency
What are the presenting symptoms and signs of Septic arthritis
Hot, Swollen, Painful joint(s) + Restriction of movement
Fever + Rigors
Knee most common site of infection
What are the main investigations necessary in Septic arthritis
Joint aspiration
Blood cultures prior to antibiotics
CRP/ESR/WCC - Elevated but not diagnostic
What are the important characteristics of Rheumatoid arthritis
It is a chronic systemic inflammatory disease
Symmetrical, deforming, peripheral polyarthritis
Increases risk of CVD (Maybe attributed to higher incidence in smokers) and is associated with HLA-DR1 & DR4
Potential extra-articular features
What are the typical and less typical presentations of Rheumatoid arthritis
Typical: Symmetrical swollen, painful, stiff small joints of hands and feet - Worse in the morning. Fluctuate and large joints may become involved.
Possible presentations (No need to learn):
Sudden onset widespread arthritis
Recurring arthritis of various joints
Persistent monoarthritis
Systemic illness with extra-articular symptoms - Fatigue, fever, weight loss, pericarditis, pleurisy
Polymyalgic onset - Vague limb girdle aches
Reccurent soft tissue problems
What are the early and late signs of Rheumatoid arthritis
Early (Inflammation no damage):
Swollen - MCP, PIP, Wrist or MTP joints.
Reduction in range of motion
Tenderness
Later (Joint damage, and deformity):
Ulnar deviation and subluxation of the wrist and fingers
Boutonniere and swan-neck deformities of fingers or z-deformity of thumbs occur.
Hand extensor tendons may rupture.
Wasting of small hand muscles
Palmar erythema
Rheumatoid nodules - firm subcutaneous nodules
Elbows, ulnar margin, palms and over extensor tendons
What are the main investigations need for Rheumatoid arthritis
Rheumatoid factor 60-70%
XR - Deformity, Osteopaenia, Narrowing of joint space, Soft tissue swelling
Anaemia of chronic disease
ESR/CRP/Platelet - Elevated
What is Reactive arthritis
This is a sterile arthritis that occurs after an infection elsewhere in the body (GI or UG)
Who is usually affected by Reactive arthritis
Young men (20x more common)
HLA-B27 associatino
GI - Salmonella, shigella, yersinia, campylobacter
UG - Chlamydia
What are the signs and symptoms of Reactive arthritis
Arthritis - Asymmetrical oligoarthritis - lower extremities - Sausage-shaped digits
Conjunctivitis
Urethritis - Burning or stinging when passing urine
Sacroiliitis - Lower back pain
Enthesitis - Painful heel
Oral ulceration Circinate balanitis Keratoderma Blennorrhagica Nail dystrophy Hyperkeratosis Onycholysis
Reiter’s Triad: Conjunctivitis, urethritis, and arthritis
What are the investigative findings in Reactive arthritis
ESR/CRP - Elevated
XR - Sacroiliitis and enthesitis
HLA-B27
What is Osteomyelitis
Infection of the bone leading to inflammation, necrosis and new bone formation
Staph A
Group A Strep
Who is affected by Osteomyelitis
Young children
Trauma
Operative
Ulcers
DM Immunosuppression IVD Prosthesis Sickle-cell anaemia
What are the signs and symptoms of Osteomyelitis
Pain Fever + Rigors, Malaise Erythema Tenderness Swelling Warmth Limited movement Seropurulent discharge
What are the investigative findings in Osteomyelitis
ESR/CRP/WCC - Raised
XR - Acute disease - Osteopenia appears 6-7 days after infection onset
What is Polymyalgia rheumatica
Inflammatory condition characterised by severe bilateral pain and morning stiffness of the shoulder, neck and pelvic girdle.
Associated with GCA
What are the common signs and symptoms of Polymyalgia rheumatica
Limb girdle stiffness and pain
Morning stiffness of greater than 45 minutes
Symptoms worse when waking
Low-grade fever + other flu like features
What are the appropriate investigations for Polymyalgia rheumatica
ESR/CRP - Elevated
US - Bursitis/Joint effusion
What is the treatment of Polymyalgia rheumatica
Coricosteriods - Oral Prednisolone 15mg/day generally response should be very quick
Monitor for adverse effects of steroids
Methotrexate may be considered for patients with prolonged therapy
What are Idiopathic inflammatory myopathies
A heterogenous group of skeletal muscle that have in common - Proximal muscle weakness and inflammation on muscle biopsy
Polymyositis
Dermatomyositis
What are causes of the Idiopathic inflammatory myopathies
They are both autoimmune diseases with viral infection being implicated
Who is usually affected by the Idiopathic inflammatory myopathies
Polymyositis - 30-60
Dermatomyositis - Any age (Biphasic)
Both are more common in women
What are the signs and symptoms of Polymyositis
Bilateral proximal muscle weakness, wasting and myalgia
If the muscles of the pharynx or oesophagus are involved then this can lead to dysphonia and dysphagia
What are the signs and symptoms of Dermatomyositis
Bilateral proximal muscle weakness, wasting and myalgia
If the muscles of the pharynx or oesophagus are involved then this can lead to dysphonia and dysphagia
Rash:
- Purplish rash on upper eyelid with oedema (Heliotrope)
- Rash around the whole upper girdle (Shawl rash)
- Facial rash
- Gottron’s papules (Red scaly rash on knuckles and elbows)
- Nail fold changes
How is Polymyositis diagnosed
Definitive diagnosis: Muscle Biopsy - Endomysial inflammatory infiltrates, Muscle necrosis, atrophy, muscle fibre regeneration
Creatine kinase - Up to 50x normal
EMG - Reduced activity
Antibodies: ANA, Anti-Mi-2, Anti-SRP, Anti-Jo-1
Myoglobin - Useful for disease severity
Enzymes less specific than CK: Aldolase, LDH, ALT
How is Dermatomyositis diagnosed
Definitive diagnosis: Muscle Biopsy - Perifascicular atrophy, Perivascular/Perimysial inflammation
Creatine Kinase - Not as useful in Poly EMG - Reduced activity Antibodies: ANA, Anti-Mi-2, Anti-Jo-1 HLA-DR3/5 Association Myoglobin - Useful for disease severity
Enzymes less specific than CK: Aldolase, LDH, ALT
What are Vasculitides
These are inflammatory disorders of blood vessels
It may be primary or secondary to another disease: SLE, RA, HEPB/C, HIV.
How are Vasculitides classed?
By the type of vessel they affect
Large: Giant cell arteritis, Takayasu’s arteritis
Medium: Polyarteritis nodosa
Small: Microscopic polyangiitis, Eosinophilic granulomatosis with polyangiitis (Churg Strauss Syndrome), Granulomatosis with polyangiitis (Wegener’s Granulomatosis),
All: Behçet’s disease
Outline Takayasu’s arteritis
What: Aorta and it’s major branches
Epi: Young women (Asian)
Signs and symptoms:
- Turbulent blood flow leading to bruits (Potentially in all major arteries)
- Blood pressure asymmetry
- Reduced or absent peripheral pulses
- Limb claudication
- FLAWS
Diagnosis:
- CT Angio/MRA showing skip lesions
Outline Polyarteritis nodosa
What: Skin, Renal and mesenteric
Epi: Hep B individuals - Rosary sign on renal angiogram
Signs and symptoms:
- Joint & Muscle pain
- Skin rash - Livedo reticularis
- Palpable purpura
- Peripheral neuropathy
- GI bleeding
- Renal failure
- HTN + MI
Diagnosis:
- Angiography - Cluster or small aneurysms
- Biopsy (Skin, Blood vessels, nerve, muscles…)
Outline Microscopic polyangiitis
What: Non-granulamatous inflammation in blood vessel of: Eyes, Larynx, Lungs and Kidneys
Epi: Middle Ages
Signs and symptoms:
Similar signs and symptoms to Wegener’s but more of the glomerulonephritis aspects
Diagnosis:
- pANCA
- Biopsy of affected organ (Skin, Kidney or Lung)
Outline Eosinophilic granulomatosis with polyangiitis (Churg Strauss Syndrome)
What: Granulamatous inflammation with Eosinophilia in blood vessel of: Eyes, Larynx, Lungs and Kidneys
Epi: Hx Atopy
Signs and symptoms: Similar signs and symptoms to Wegener's but with Allergic symptoms beforehand - Asthma - Chronic rhinosinusitis - Blood Eosinophilia - Peripheral neuropathy
Diagnosis:
- pANCA
- ECG
- Echo
Outline Granulomatosis with polyangiitis (Wegener’s Granulomatosis)
What: Granulamatous inflammation in blood vessel of: Eyes, Ears, Nose, Larynx, Lungs and Kidneys
Epi: White
Signs and symptoms:
- Eyes - Painful exophthalmos, Diplopia, Optic nerve ischaemia, Sceritis or Uveitis
- Ear - Otitis, Deafness
- Nose - Saddle nose deformity, Recurrent sinusitis
- Larynx - Hoarse voice, Collapse
- Lung - Nodules (Biopsied)
- Renal - Glomerulonephritis, KF
Diagnosis:
- cANCA
- Biopsy of affected organ (Skin, Kidney or Lung)
Outline Behçet’s disease
What: Affects all vessels
Epi: Greek, Turkish, HLA-
Signs and symptoms:
- Recurrent oral ulcers (Larger, more painful, and longer to heal than Aphthous ulcers) - Almost continuously present
- Genital ulcers
- Anterior Uveitis - Sterile pus (Hypopyon), Painful, Redness
- Posterior Uveitis - Painless, floaters, decreased vision
- Folliculitis
- Erythema nodosum
- Arthritis
- Colitis
Diagnosis:
- Clinical based on symptoms
- Pathergy test - Pin prick becomes an ulcer after 2 days
